Why are so many family doctors in Nova Scotia reporting feeling burned out?

The answer can be found in the average working day of a community-based family physician, one who’s paid — as the majority of family docs here are — on a fee-for-service basis.

Details follow. But, to summarize, many fee-for-service family doctors are finding themselves working long hours, day after day, in an exhausting attempt to just tread water financially.

When I say fee-for-service, I mean what MSI pays a doctor for a defined primary health-care service. Right now, for example, MSI pays family doctors $31.46 for an office visit by a patient.

Most fee-for-service family doctors in the province work in small practices, usually one to three family physicians. They cover, or share payment for, all overhead expenses, such as rent, utilities and staff salaries, for their offices or clinics.

Family doctors I’ve talked to say overhead can eat up 30 to 40 per cent of their overall earnings.

Since they’re self-employed, they don’t get paid when they’re too sick to work or need time off, for instance maternity leave. Vacations, if they take them, must also be totally self-financed. So family physicians try to build up funds for those contingencies.

Meanwhile, younger family physicians often also have sizable student loans to pay off.

So, before even talking about take-home pay, there are a lot of claims on a family doc’s income.

Now, let’s look at that MSI payment to family doctors — $31.46 for an office visit.

For $31.46, family doctors say, they’re expected to review prior test results or specialists’ findings on a specific patient, meet with the patient when they’re in and make notes, order any needed new tests or request new referrals, conduct any required telephone consultations, and so on.

Given the amount they’re paid per patient’s office visit, to make the ends meet and take home a reasonable level of income, family doctors know they must see, on average, a set minimum number of patients per day — say 25 to 30.

That’s why so many family doctors schedule people in 10-minute increments. That why so many ask that patients bring up only a single issue per visit, because they don’t get a cent more for dealing with the same patient’s other health issues during the same visit, I’m told.

It’s not that community-based family doctors don’t care. They say it’s the cold, hard math of the fee-for-service system that says they can’t afford to spend 30 minutes with every patient.

Of course, there’s no way to do everything that $31.46 is said to cover in 10 minutes. So family doctors review tests, etc., early each morning, before seeing patients. And they keep working after scheduled appointments are done, writing referral letters, etc.

One family doctor I know estimates they’re often on the job from about 8 a.m. every morning to 7 p.m. every evening. They estimate they have up to two hours of paperwork daily that are related to office visits but done on the doctor’s time.

Meanwhile, their patients are getting older. Given Nova Scotia’s unhealthy population relative to the rest of Canada — with higher levels of obesity, diabetes, etc., here — even many younger patients present with multiple serious health issues.

That means a 10-minute goal per patient goes out the window.

Even higher MSI fees of $49.92 for office visits for geriatric patients (over 65) — intended to offset the extra time required — only go so far, family doctors say.

A recent improvement was a MSI fee of $28 for telephone visits — four times a year per patient.

Bottom line: Community-based family doctors in Nova Scotia are the lowest paid in Canada. For too many of those physicians, maintaining those levels has become exhausting.